Psychiatric holds and refusal of medical treatment

June 19th, 2010

I apologize for the stagnant blog of late. I’ve been working on an idea or two that hasn’t jelled yet. Meanwhile, I ran across a familiar yet troubling occurrence the other day: The use of a psychiatric hold on an inpatient with no psychiatric disorder but who was refusing life-saving medical treatment.

My comments are limited to California, as each state has its own laws about psychiatric holds, a.k.a. involuntary civil commitment. The Lanterman-Petris-Short (LPS) Act, signed into law by Governor Ronald Reagan in 1969, made California the first state to employ a “dangerousness” standard to justify psychiatric holds. Prior to this, mental patients were generally committed on the basis of “need for treatment.”

Dangerousness is defined in the LPS law as danger to self (usually interpreted as intentional self-harm or suicide risk, not mere recklessness), danger to others, or grave disability (inability to provide for one’s own food, clothing, or shelter). For LPS provisions to apply at all, the alleged dangerousness must be the result of a mental disorder or chronic alcoholism. The LPS Act is part of the state Welfare and Institutions Code, sections 5000 and following. The initial 72-hour hold in California is called a “5150” as it is authorized in section 5150 of the WIC. Here is a brief history of California mental health law.

Virtually all other states adopted psychiatric commitment laws similarly based on dangerousness after the US Supreme Court ruled in O’Connor v. Donaldson, 422 U.S. 563 (1975) that, “There is…no constitutional basis for confining such persons involuntarily if they are dangerous to no one.”

Let’s turn now to a non-psychiatric setting, the general medical-surgical hospital. Some hospitalized patients cannot make informed medical choices, or they may express unpopular, “crazy” opinions. At one extreme are patients who arrive unconscious and cannot express a choice at all. In the typical emergency situation, doctors and nurses reasonably assume such a patient wants to receive lifesaving treatment, and proceed accordingly. Other patients may be delirious, in great pain, or suffering from a brain injury or stroke. They may express preferences that make no sense to the medical professionals, choices that seem “crazy.” (Questions about decision-making capacity almost never arise when the patient agrees with the doctor, only when there is disagreement.)

These situations have nothing to do with psychiatric illness. It is well recognized that some patients lack the capacity to make medical decisions while in the throes of severe illness or injury. As with the unconscious patient, lifesaving treatment proceeds with assumed consent. No one lets a confused delirious patient stagger out of the hospital just because he lurches blindly in that direction.

More challenging ethical dilemmas arise when a refusing patient is simply uneducated or from another culture. When I was a medical intern, I saw an elderly Filipino man with intestinal bleeding. He had never been seriously sick before, and did not understand Western medicine. He refused blood transfusion on the theory that “the more you put in, the more will leak out.” The senior medical resident requested a psychiatry consult to declare the man incompetent to make such decisions. (This was a mistake, as I’ll explain shortly.) He then received transfusions against his will. Soon thereafter the patient refused surgery needed to stop the bleeding. The surgeon proclaimed he would never operate on an unwilling patient — but in an odd twist, when the patient lapsed into unconsciousness, he was “no longer objecting” and the surgery proceeded. The patient died in the post-surgical ICU, never having regained consciousness.

This sad case highlights a few important points I’ll just touch on here. First, assessment of medical decision-making capacity is not a special skill of psychiatrists. All physicians are supposed to do this routinely (albeit usually implicitly). Internists need to know whether their patients can give informed consent for medical treatments, and surgeons should likewise assess the capacity of their patients to consent to surgery. “Competence” is an overarching legal status decided by a court, not by medical or psychiatric assessment alone. Perhaps the most obvious point: Once a patient’s consent or refusal is considered valid, its ethical force doesn’t diminish when the patient falls asleep or lapses into unconsciousness.

Now, how does the “5150” apply in the non-psychiatric hospital setting? Hardly at all. Patients with severe mental illness are sometimes hospitalized for unrelated conditions, and occasionally meet dangerousness criteria for a 5150 hold while receiving medical treatment. But the more common situation is the misuse of the “5150” to prevent an apparently lucid patient from refusing lifesaving medical or surgical treatment and leaving the hospital. This is startlingly common — it startles me, anyway — and happened just the other day at my hospital.

It should be obvious why the 5150 cannot be used this way. First, it only applies to a situation in which a mental disorder or chronic alcoholism leads to dangerous behavior. Second, refusal of lifesaving medical treatment is not “danger to self” as the law is normally understood. Third, even a legitimate 5150 hold only compels three days of psychiatric evaluation and protective custody; it says nothing about forcing medical or surgical (or even psychiatric) treatment on anyone.

The solution is for physicians to assess the medical decision-making capacity of their own patients. Where available, a hospital ethics consult can clarify the relevant issues, but this is usually optional. Patients who possess medical decision-making capacity have the right to refuse treatment and to leave the hospital if they wish, even if they die as a result. Those who lack such capacity can be treated, like the comatose or delirious patient, with assumed consent. However, a superior court determination of incompetence to make medical decisions is required to force non-emergency medical or surgical treatment. LPS law is silent on these matters.

87 comments to Psychiatric holds and refusal of medical treatment

I am assuming you would advocate for other measures that might fall between forcing the treatment and just letting a patient go. Seeking people who a patient might trust, for instance, to provide explanation of a situation in a perhaps more culturally comprehensible manner.

Absolutely. You make a very good point. Since my focus was on the misuse of the “5150” psychiatric hold, I neglected to discuss (or, to be honest, think about) strategies the treating doctor or team might use to obtain truly informed and meaningful consent. As you note, providing a cultural liaison can be very helpful. This might be a medical professional who belongs to the patient’s identified cultural group, for example, or a member of the patient’s own family who is more medically sophisticated. Certainly a language interpreter is essential if the patient does not speak English well. There are also interesting cases where a patient objects to a treatment on religious grounds, and a clergy member of their faith is able to come to the bedside and explain that the treatment is actually allowable (assuming it is).

If there is time, often the simplest and most effective strategy is to let the patient ponder the decision for awhile without undue pressure, and with whatever written information (e.g., on risks and benefits) may be relevant. People need time to collect their thoughts and sort through their feelings. Thank you for writing.

What about psychiatric evaluations of suicidal patients? Are these patients allowed to refuse non-emergency medical treatment or even life-saving treatment? Can a court order force them to have this treatment and is there any court case precedence for this? Thank you for replying back.

In the medical centers I know, hospitalized medical or surgical patients who express suicidal feelings are evaluated on-site by a psychiatrist for suicide risk. High-risk patients receive a “5150” status by the consulting psychiatrist. This means the patient is kept in the hospital involuntarily while being treated for the original medical or surgical problem; someone, usually a nursing aide, is paid to watch him or her to prevent intentional self-harm. Afterwards, the patient is usually transferred to the psychiatric wing of the hospital. Such patients rarely refuse the non-emergency treatment they choose to be admitted and treated for it in the first place. A court-order could force such treatment, but I can’t cite you specific cases. People routinely refuse lots of recommended care for all sorts of reasons. A court would only get involved if the refusal had serious consequences, such as death or permanent disability, and the refusal seemed irrational or plainly suicidal.

As I wrote in the original post, emergency treatment is almost always performed with implied consent, even over a patient’s objections. (One obvious exception is when a terminal patient refuses “heroic” lifesaving measures.) Patients who have just overdosed, shot themselves, etc. in a suicide attempt are saved, no questions asked. I can imagine ethically difficult dilemmas involving coherent, lucid patients suicidally refusing life-saving emergency treatment, but thankfully this is rare.

Performing psychiatric evaluations on patients hospitalized for non-psychiatric reasons is a specialty called consultation-liasion psychiatry (a newer term, psychosomatic medicine, is also becoming popular). Such specialists need a broad knowledge of general medicine and surgery, at least as these diseases, and their treatments, relate to mental functioning. I am not trained as a “C/L” psychiatrist myself.

I believe the 5150 would still be in place, although I cannot recall any instances of this situation actually happening. As I wrote above in my comment to J Fretwell, a patient on a 5150 who is being treated on a medical or surgical floor would be watched continuously by a nursing aide or other staff person, until either the 5150 is dropped or the patient is transferred to a secure psychiatric setting.

In our acute medical hospital, we work off the understanding that a 5150 hold placed outside the hospital is null and void upon admission. The patient is re-evaluated by licensed staff and a new hold is started, if appropriate.

I’m sure you’re right, not only at your facility, but at mine too. All legal holds are re-evaluated upon admission. My response to Anonymous may have implied otherwise, as I thought the question was whether psychiatric holds remain in place in medical settings. They do. I wasn’t thinking procedurally about who places such holds, and how they are re-evaluated. Thanks for writing.

I received a patient in the ED last week where a “5150” was initiated at his mental health clinic. The pt was sent to our ED for medical clearance as the pt was having c/o CP. I called the clinic back alerting the pt is medically cleared and will return to the clinic. The medical director of the clinic said no it was the ED’s responsibilty to transfer the pt and it was two late for them. I advised it was a “dump” on their part, they already had a MAC # so they just had to coordinate the transfer. Since it was 3pm on a Friday it was surely obvious it was a bit of an inconvenience for the clinic. I advised them that the pt was no acutely SI/HI or psychotic, the hold was GD which was incongruent with the presentation of the pt, and the pt was evaluated and placed on a hold with a BAC above .1. I added that our hospital is non designated and their 5150 is “null and void”. They disagreed, however took the pt back. I was hoping perhaps you can give me some insight and advise if I was incorrect in my stance with the situation.

In the situation you describe, the clinic presumably applied a 5150 for “grave disability” (GD) in order to get a refusing patient transported to the emergency department (ED) for evaluation of chest pain (CP). If so, this was a misuse of the 5150, much like the inpatient examples in my original post. While I empathize with the clinic staff in this difficult situation, I believe the correct approach would have been to call 911 for the chest pain, and have the EMTs/paramedics assess whether the patient needed ED evaluation, and whether he or she had capacity to refuse it. I imagine there are similar scenarios where concerned family members call 911 on behalf of a loved one who is in denial about his chest pain. It might make for an awkward scene, but no 5150 or psychiatric evaluation would even be considered.

I haven’t worked in an emergency setting in many years, so I may have missed some details. I’m not certain what relevance the blood alcohol level (BAC) has here, nor what a “non designated” hospital is. The details of how patient transfers are coordinated is beyond me. But I do know that a 5150 applied prior to transport can be dropped by the evaluating psychiatrist in the ED. This happens quite often with temporarily suicidal or agitated people brought in by police on a 5150: They calm down after some time and are released. Assuming you are a psychiatrist, you were correct to drop the 5150 if you felt the patient did not meet dangerousness criteria. Thanks for writing.

Involuntary commitments routinely and regularly disregard both state and federal law;however, since those very same frameworks do not have effective mechanisms with which to enforce human, civil, and constitutional rights for patients, those overwhelmingly remain. As such, any discussion of the correct procedures therein are intersting and imply widespread compliance by the mental health megalopoly, but are highly misleading for the general public.
Thank you for presenting it though.

My 24-year old sister-in-law has a list of major medical problems (Crohn’s, kidney infection, MRSA, G-tube infection) and recently had to have an abortion due to other medical issues. She’s been in severe pain most of her life and recently started injecting vodka into her G-tube. She says that it’s to control her pain and because she no longer wants to be awake since she’s so upset due to the recent abortion. Last Friday she overdosed on Oxycontin, Valium and alcohol (1.8L in 8 hours) injected into G-tube. She was rushed to the hospital and is alive. She is extremely angry that the family saved her and has been lashing out at hospital staff and family. At my mother-in-laws request, the hospital did a psych eval and completed a 5150. She has been in restraints since her arrival because of aggression. The hospital says it’s going to release her tomorrow, June 22, if they can’t find her a bed at a pyschiatric facility. “Nobody will take her because of her MRSA” is what the hospital is stating. The family knows she will try to kill herself if she is released. Doesn’t somebody have to take her legally? What can we do?

This awful situation is quite different than what I was writing about, but here are some thoughts. First, despite arguments that people in pain and great medical distress ought to be able to commit suicide, I feel the 5150 was entirely warranted here. Your sister-in-law is not terminally ill; she attempted suicide in the midst of an acute, and presumably transient, emotional upheaval. If prevented from acting impulsively, the storm is likely to pass, and she may well be grateful in the future that she is still alive.

The problem of being refused psychiatric hospitalization due to complex medical needs is a real dilemma. Most psychiatric hospitals are not staffed or equipped to handle these needs, and I understand their hesitation to admit someone with MRSA. There are “med-psych” units designed for such patients, but these are few and far between.

In our mostly free-market health care system, no particular hospital “has” to take her. However, the hospital that has her now cannot cancel a 5150 simply because they can’t find her a bed elsewhere. They would have to assess and document that she is no longer suicidal. This is a judgment call, of course. But if the hospital releases her despite clear evidence of suicidal risk, this would open them to a potential lawsuit, and may violate California’s Welfare and Institutions code. Thanks for writing, and good luck.

The fire arm prohibition is for a lifetime according to federal law only when a 5250 is instituted. As for a null and void 5150, in CA, it is only null and void if a patient is in a non-designated medical facility and is medically compromised, being kept there for medical treatment past 24 hours. Custody is still maintained and if the patient is medically clear within the span of 72 hours and still 5150-able, that is meets criteria (LPS), credit is given from inception of the 5150 and must be transfered to a designated facility. If the 5150 expires while being medically treated, the patient must be re-evaluated prior to discharge.
When a person comes into an emergency department on a 5150, it cannot arbitrarily be terminated simpy because that person is coming into a non-designated facility. This is against CA & federal law.
You may want to look up these laws and statues.

As an ex-EMT turned medical student, the issue of the improper use of WIC 5150 as a substitute for implied consent (either because the patient absolutely has capacity and wants to refuse care, or because the patient falls into the gray area of using some sort of intoxicating substance, but may not be to the point of losing capacity) comes up frighteningly often in online EMS forums. Due to the multiple legal and social consequences surrounding a 5150 hold, are you aware of anyone in health care or law enforcement facing civil or criminal liability for the blatant abuse of WIC 5150 against someone who is not suffering from a mental disorder?

I am not a first-responder nor do I read online EMS forums — I assume this issue arises much more often outside of hospitals. Since the evidentiary standard for 5150 (and 5250) is only “probable cause”, I imagine it would take a clear pattern of repeated abuse, or a particularly egregious example of blatant abuse, before someone faced civil or criminal liability. I’m not personally aware of anyone who has. Thanks for writing, and good luck in your new career. Oh, and nice work on your blog (click his name).

In our EMS System in LA County, our policy regarding “consent” instructs those of us providing pre hospital care NOT to assume that someone that has drugs or alcohol on board is “competent” to refuse care and as such, we are required to treat such patients under “implied” consent. This, at least in the field setting for EMT’s and PM’s, eliminates the need for requesting Law Enforcement to implement a 5150 but of course this would have to be re-evaluated at the receiving hospital.

Ref. 834 under “Principles:” says that “3. A patient determined by EMS personnel or the base hospital to be incompetent may not refuse care AMA or be released at scene. Mental illness, drugs, alcohol intoxication, or physical/mental impairment may significantly impair a patient’s competence. Patients who have attempted suicide, verbalized suicidal intent, or if other factors lead EMS personnel so suspect suicidal intent, should not be regarded as competent.”

If followed, it would not be necessary for 5150’s to be implemented in many of the patients you describe in the first place, you just treat on “implied consent” and let them sort it out at the hospital.

I realize this policy leaves lots of room for “lawyering” and can be called into question in a variety of ways but the underlying premise is that given the limited training and diagnostic capability of prehospital care personnel, it is better to ere on the side of treating and transporting the patient than it is to withhold care.

Finally, I always try to view my care from the perspective of a Juror in a lawsuit. From a purely CYA perspective, an award for damages for providing care against a patients will when there is a question re: his/her competence vs. an award for damages for withholding care when there is q question re: his/her competence is certainly going to much smaller if one is awarded at all . I teach my students to ere on the side of treatment.

While not trying to hijack the comment section (too much at least), I don’t have a problem with EMS transporting someone who is intoxicated under implied consent. The problem is that “alcohol on board” covers a huge range, much of which doesn’t necessarily remove capacity (the proverbial 2 beers). My problem with 5150s is that a 5150 is very very specific in what it applies, and a patient who lacks capacity because of alcohol is not the same as lacking capacity from a mental illness.

The ironic thing is that WIC 5170 is basically a 5150 specifically for people who are drunk. It also doesn’t carry the same long term restrictions like what 5150 holds and firearm ownership.

I saw a patient on a med-surg floor who was on a 5250(14 day hold) The entire facility is designated so the hold was OK. The patient had head lice and was refusing to the point of being agitated to comply with shampoo. The patient was in an isolation room. However, the psychiatrist phoned an order for PRN of Haldol, Ativan and Benadryl. After that the patient was shampooed. Is this in your opinion a violation of the patients right to refuse? Or is there another issue I am missing.

I believe the technical approach is: If patients normally have the right to refuse treatment for lice, does this patient lack capacity to give informed consent or refusal? (I frame it this way because I’m uncertain how hospital policies deal with lice. Maybe as a public health matter, hospitals don’t allow even lucid patients to refuse treatment.) If this patient lacks capacity, then treatment can be imposed via the principle of substituted judgment, i.e., the doctors (or a designated decision-maker if one is on hand) decide what the patient would want if he had capacity, or what is in his best interest if his usual preferences are unknown. The use of medication — I’m assuming by mouth, not injection — allows the treatment to take place, and was likely the “least restrictive” of the available options.

More pragmatically, minor hospital interventions such as shampooing, wound disinfection, bandage changes, etc, are generally not subject to careful consideration of informed consent. Patients are often pre-medicated to make such interventions easier to tolerate and perform.

Either way, the patient’s 5250 legal status is immaterial. Patients admitted voluntarily, i.e., without a psychiatric hold, are treated this way too. Moreover, a 5250 does not permit involuntary psychiatric medication when it would otherwise not be permitted. In California this requires a “Riese hearing.” Note that involuntary psychiatric treatment has more legal restrictions than involuntary medical treatment. Shampooing for lice is definitely an example of the latter, and even the medications here are being used “medically” not “psychiatrically”. That may sound odd, but Haldol and Ativan are used all over hospitals without a psychiatrist, or a psychiatric diagnosis, in sight.

Hi, I just had a question. If you are an emt and you arrive on site, the pt. suffered a seizure before arrival, refuses care, intoxicated, and sibling is claiming that pt. is suicidal. Pt. is denying it. What do you do ? La county

[I cleaned up the grammar to make this readable. It’s off-topic, but I’m publishing it anyway, in case another reader wants to comment. — SR]

My mother is Schizophrenic and suffers from times where she is lucid and other times where she is totally irrational. Dealing with her in the past as I would do another person is difficult, as she truly believes that everyone is to blame for the problems that she faces. She sometimes has the victim mentality, but it is mostly a mentality of she being better than the rest of the world. I had once convinced her that she was wrong through many hours of persuasion, but this caused her to become angry. I would describe it as her wanting to do what is good and right, but always doing the opposite. I’m sure if I confronted her about it that I would hit the nail on the head and elicit some tears, something that she hasn’t done in years. It seems like the only emotions she expresses is anger and sadness, and only when those are convenient to manipulate those around her. I love and care for her a lot, but I can’t continue to live my life in such a way where she is allowed to say and do things that can be hateful without being put into check. The rest of the family has nothing to do with her, as my father has a restraining order against her and my brother no longer contacts her. A few years ago, when I was in my second semester in my undergraduate education, I had to get a no trespass order against her because she was beginning to use me to try to get back at my father (something she did while the two were divorcing in 2001) and I would have nothing to do with it. I was in the middle of it all when I was little, but I didn’t want to be in the middle of it all again. I know that my mom is not mentally healthy, and what really scares me to death is that she has attempted suicide in the past. She has the capability to do it again, having done it in the recent past. I know that she needs to get help, but I don’t know how to go about doing it. I plan to set the boundaries in place that she gets psychiatric help in order to have a relationship with me. I hope this will put her into the position that she does get help, but I realize that she does have the right to refuse to get care if she feels that she doesn’t need it. Thing is, she has a history of suicide attempts but has never gotten help. If I were to hear that she had attempted suicide again, how would I ensure that she gets the proper help that she needs? I have e-mails on Facebook where she had threatened to kill herself that I could send in if needed (I know that most of the time, these patients come in and the doctors don’t know anything about them). How do I help her get the professional help she needs but still allow her to have a choice? She has been highly unpredictable and violent in the past (she broke a glass over my dad’s head). Is there anything I can do to help her, or have I done all that is in my power to help her?

I also have a question about Schizophrenia. I know some about this disorder, but not too much about it. I know that it may be passed down in families and that it manifests itself in early adulthood. My grandmother on my mom’s side has it bad, and my mother hasn’t been officially diagnosed with it that I know of. I haven’t shown signs of Schizophrenia yet, but I fear that I would. What are the things that I should watch out for when it comes to signs of Schizophrenia? If I happen to not have Schizophrenia, how likely would it be that I would pass it on to my children? What should I do if I do start to notice signs of Schizophrenia?

This is all new to me right now, and I’m having to deal with it all while I am taking my pre-requisites for nursing and medical school at the same time, studying for the MCATs, and gaining outside experience in the medical field, so it can be stressful at times. I guess one thing I really want to know is how am I supposed to balance my career and my family life in such a way that is best for me and my family? How can I use my experiences to help me in medical school and beyond?

I don’t know if you can answer these questions, but it would be great if you could offer some insight.

Hi Alison, and thanks for writing. You ask several questions here (a bit off-topic but that’s ok). The most basic issue is diagnosis. You start by saying your mother has schizophrenia, but later that she hasn’t been officially diagnosed. Other conditions look like schizophrenia but have different treatment and prognosis, so the diagnosis is important. I found a good webpage that may answer some of your questions about having a parent with schizophrenia, e.g., the statistical likelihood of passing it from parent to child. I also did a short post on schizophrenia myself some time ago.

Regarding suicide attempts (or immediate plans), every state has laws that allow the police to bring a suicidal person to a facility for psychiatric evaluation. If the evaluating psychiatrist finds “probable cause” to believe the person may hurt herself or others, the person is kept in the hospital for a few days for a more complete evaluation. This “civil commitment” can be extended for ongoing suicidal risk (in California up to 1 month, other states may differ). While it is in place, the person does not have a choice about being confined. Afterwards, the patient decides whether to continue treatment — and as you’d expect, some do and some don’t. Sometimes families can apply pressure, as in demanding that the person accepts psychiatric treatment in order to have a relationship with them. This sometimes works, but it can backfire too, if it cuts off a disturbed person from the family support they need.

Your last question about how to balance career and family life is too big to address here. One small answer is to use your own experience to help yourself empathize with others. But I bet you already knew that.

Unfortunately, the whole family has had to cut contact with her, as having contact with her was more harmful than beneficial, so she has no family support at the moment. What scares me the most is that, the last time I know, she has a couple of my prescriptions for Vicodin and Percoset, and she is pretty much isolated from people. She used to date a lot, but I don’t know if she has continued that. I was the closest that she was to having a relationship, and she even pushed me away a lot of times. She is never consistent, except in her being angry.

So, let me see if I’m getting what you’re saying right. At this point, she probably needs to see someone for a definitive diagnosis at this point. That might be hard, but I think that the distance from the family might be the way to do it. Like you said, it can backfire, and the way that I see this happening is another suicide attempt. People have told me in the past that if she did do this, that it isn’t my fault. I know that they are right, but it doesn’t make the prospect that much easier.

And thanks for your post. I don’t have time to look at the websites at the moment, but I will definitely look at them later.

I did look at the websites that you gave me, and it’s made things a little more clear for me. A huge thing you had mentioned is that people with Schizophrenia tended to be isolated from other people. Throughout my teenage years, she was often isolated from other people and was (and still is) incapable of holding a job for more than a few months. She often hid this fact from me by placing blame on the other people, but there were a few times that I had met a few of these people and I found that these people weren’t people that were hard to get along with and they weren’t what she said they were.

I have a rather complex medical-legal question. My mom is almost 80, schizophrenic, and has been living in a board and care home in CA. She’s always been extremely difficult – understandably resents the loss of her autonomy, and like many refuses to acknowledge her illness and refuses treatment/psych meds. She’s been so generally uncooperative with the staff, they let her be in a state of “benign neglect,” where they mostly leave her alone (she’s not currently under conservatorship, altho has been in the past). Recently, she fell and altho was banged up, she refused to go to the hospital or to be examined by any visiting doc. It’s not clear why she fell, she spoke of feeling dizziness just before & I worry she may have had a stroke or TIA. Can she be compelled to be hospitalized/examined, to submit to tests for these 2 possibilities? If present, they could be life-threatening. She isn’t exhibiting signs of a stroke (slurred speech, difficulties with one side of body, etc.). Any entreaties by me or by staff haven’t persuaded her to consent. Thanks for your insight.

Hi Irene,
My understanding is that a patient cannot be compelled to accept medical treatment unless (1) the situation is a life-threatening emergency and the patient is deemed to lack decision-making capacity, or (2) a court orders the treatment. From your description, it doesn’t sound like #1 applies, as the situation is not an emergency. A court order is essentially a determination of incompetence to make medical decisions for oneself, and can apply to a single decision or in general. The latter is called a conservatorship (different than a psychiatric conservatorship); the court assigns a conservator to make medical decisions for the person going forward. If agreeing to medical care is an ongoing problem for your mother, you may wish to explore this option.

While this is my understanding of how the law works in California, it wouldn’t surprise me at all if elderly, difficult, schizophrenic people living in board and care homes were routinely taken for medical checkups over their objections. Doing so exposes the staff to legal liability — potentially even criminal charges of assault and battery — but that doesn’t mean it never happens.

IF POLICE WRITE A 5150 HOLD IN THE FIELD FOR A SUICIDAL/HOMICIDAL PATIENT.THEY TRASNPORT THE PATIENT TO A NON-PHYSIATRIC MEDICAL FACILITY SUCH AS A NON TRAUMA ED. THEY TURN THE PATIENT OVER TO THE ED AND LEAVE IS THAT 5150 HOLD VALID? OR DOES THE POLICE NEED TO SIT ON BEDSIDE UNTIL TRANSFERED ?

My wife has been hospitalized because she told the police, while drunk, that she had taken pills. She’s bi-polar, and needs her medicine that’s been prescribed to her by her psychiatrist of two years, but the hospital has not given it to her for one night (she skipped the night before) and refuses to do so until she sees their staff psychiatrist, who knows nothing about her case.

She’s already dropped into a severe depression and I’m afraid they’re going to hold her until they’ve changed her medicine (not needed) and are satisfied she’s no longer a danger to herself.

She’s been in the hospital for 36 hours now; they have her psychiatrist’s name, but they haven’t called, no psychiatrist from the hospital has seen her yet, and they will not communicate with me.

Can I take her out of the hospital? Can I sue for negligence? I’m not one to want to sue, but I’m so angry of her lack of treatment that I can’t see straight. Help!

I’m sorry you and your wife are going (or recent went) through this. Many real suicide attempts occur during intoxication, so police and ER psychiatrists tend to err on the side of safety, i.e., hospitalizing on a legal hold. There is no excuse for a patient not seeing a hospital psychiatrist for 36 hours, though.

I’m not an attorney, but as I understand it you can challenge involuntary commitments legally, and can also sue (or even press criminal charges) after the fact. Bear in mind, though, that in California at least, the standard of evidence for involuntary commitment is only “probable cause”: The treating doctors don’t have to prove the person is at risk, only that the risk is “probable.” You may have a case for negligence or malpractice if your wife really wasn’t seen for 36 hours (I’m thinking she may have been, and you weren’t informed). A lawyer could clarify your options. Good luck.

I work in the emergency room. Can a 5150 patient refuse lab draws to determine medical clearance? We had a 5150 hold that was refusing bloodwork. A psych evaluator would not come to see patient until labs resulted and patient was medically cleared. We were at a standstill. At the end of 72 hours, would the patient have to be released? A waste of resources to watch this patient for 72 hours.

I should preface this by saying I don’t do ER work and am not an expert on medicolegal matters. But I’ll tell you what I (think I) know. Patients can refuse all medical interventions, including labs, except when the situation is deemed a medical emergency, or when the patient is conserved. This is unrelated to 5150. So if your patient was wildly agitated and delirious — a medical emergency — you could take labs despite the patient’s (apparent) objection, whether there was a 5150 or not. Conversely, if there was no apparent medical emergency, you couldn’t.

Your psych evaluator needed to see the patient whether labs were done or not. You can’t keep a patient on 5150 status without a psych eval done by personnel at the holding institution. As an ethical matter, the patient deserved to be evaluated for the need for a hold; maintenance of a 5150 cannot be used as punishment or coercion to get the patient to agree to medical interventions, including labs. And patients can be assessed for danger to self or others without the evaluator necessarily knowing the cause (medical or psychiatric) of the dangerousness.

If others have thoughts/experience with this, feel free to comment. Thanks for writing.

SOME STAFF IN CA. CLAIM PATIENTS ON 5150’S LOSE THAT STATUS
ONCE MOVED TO A MEDICAL UNIT.
IM NOT FINDING THIS CLAIM EITHER IN THE LAW OR YOUR WELL THOUGHT OUT RESPONSES.
ANY HELP?
RESPECTFULLY, CA,BEHAVIORAL HEALTH C.D.A.C.STAFF

Here’s how it worked in several Bay Area hospitals where I practiced. Remember, I’m not a lawyer, and this is not legal advice… just my experience and opinions.

When a patient on a 5150 is transferred to a medical unit in the same facility, 5150 status is maintained unless and until it is canceled by a consulting psychiatrist, or until it expires automatically after 72 hours. (Any patient on 5150 status should have a consulting psychiatrist following closely. Such consultants rarely let a 5150 expire naturally: it’s either dropped by direct order, or extended to a 5250.) Typically a “sitter” is provided on the medical unit to assure that the patient doesn’t leave, or hurt himself or others. The sitter does not need to be specially trained; he or she is only there to alert other staff or security personnel if the patient acts dangerously. Restraints, i.e., tying the patient to the bed, is not done routinely, as the law requires the “least restrictive” alternative to maintain safety. Rarely, soft restraints are needed to prevent immediate self-harm. If the 5150 or 5250 is still active when the medical problem has been dealt with, the patient is transferred (back) to the psychiatry unit. If the hold has been dropped in the meantime, a transfer (back) to psych may or may not be needed.

I have a question that is off topic but relates to a psychiatric patient in a correctional setting (prison psychiatric hospital).
He has schizophrenia, paranoid type and his delusions are the primary problem. No medication has been totally effective. Navane seems to work best and he is reasonably compiant with taking the medication.
Here is the issue–he refuses to have labs drawn.
He will become agitated and violent if we force the issue. Should we continue to medicate (and try other medication{can’t use clozapine because of need for labs})or do we stop medication and let him become floridly psychotic? Of course I do not want him to become floridly psychotic because that could be interpreted as causin harm.
Any ideas?
Thank you for any thoughts and notions.

Hello Dr. Farley,
I don’t have an answer for you, and welcome comments from any readers who are prison psych professionals. In particular, I don’t know to what degree informed consent is legally and ethically required in the correctional system. Assuming it is required, and assuming this patient understands the risks and benefits of Navane treatment well enough to give informed consent, he may choose to accept the added risks of forgoing lab monitoring. (Conversely, if his refusal of labs is delusional, then he lacks the capacity to consent or refuse, and a substitute decision-maker would need to step in. I don’t know how this works in the prison setting.)

If he consents to treatment without labs, the question then falls to whether his prescribing doctor feels he or she can ethically treat him this way. Given the risks and benefits, I expect most prescribers would prefer to have labs, but would still treat if they are not available. I have faced a similar situation in my office practice, and have treated a bipolar patient with Depakote for several years without blood work — which is at least as crucial in prescribing Depakote as in prescribing Navane. Having repeatedly explained the risks he’s inviting, and given the devastation of his prior episodes, I feel the most prudent course is to treat my patient under less-than-optimal conditions. No doubt prescribers will differ in such assessments. Thanks for writing, and feel free to add your own further thoughts and notions here.

California law prohibits owning or handling firearms for 5 years after a 5150. This would disallow certain jobs that require them, such as police officer or security guard. The 5150 record is sent by the institution to the federal Department of Justice. I assume there are other jobs that require background and/or security clearances where this record could be a problem. Also, some employers ask applicants whether they have any significant mental health issues. The applicant is expected to tell the truth, but of course not all do. A past 5150 is not a “criminal record” and does not need to be reported as such.

I need your advice please. My 14 year old daughter recently attempted suicide by ingesting 20 Excedrin. After being cleared physically by the hospital she had a psych eval done that took all of 5 minutes taken by a “social worker” that had never previously spoken with her. Although we requested consult by her current psych doctor and counselor, who have been treating her for clinical depression for months, the social worker refused and told us we were being forced to put our daughter into inpatient psychiatric care. If we refused, CPS would be called. What are our legal rights as parents to refuse treatment? It sure didn’t seem like we had any. And although she did make a suicide attempt, 3 days prior, her meds had been increased, which could have been the problem; however, her current psych team was not even consulted. It seems like such an injustice to not have any say in our daughter’s treatment. Can you shed any light?

Your question, like the one just above it, concerns involuntary holds (civil commitment), and not about their use for medical treatment. Maybe I’ll post something more generally about civil commitment, so such questions can go there. Also, yours is about children, and I’m not a child psychiatrist. Nonetheless, here’s what I can tell you.

First, a suicide attempt involving 20 Excedrin is more serious than you may realize. Excedrin contains acetaminophen, which in overdose can cause acute liver failure. Emergency liver transplantation is sometimes needed, and the victim can die if the condition is not treated immediately.

Second, such a suicide attempt is prima facie evidence of “danger to self.” In other words, the social worker didn’t need a long interview or additional information to come to this conclusion. It works the same way for adults: The behavior itself is legal justification for the hold. While it’s certainly better clinically for inpatient staff to coordinate care with the outpatient psychiatrist and counselor, it’s not legally required, and in any case this can be done after the patient is hospitalized. I’ve heard that parents of minors have little or no say in such decisions, but this is outside my area.

While it sounds as though your daughter was treated as others would be in this situation, I sometimes question the clinical utility of short-term psychiatric hospitalization for regretted suicide attempts. (Obviously, if the patient doesn’t regret the attempt and still intends to commit suicide, there’s a much better argument to hospitalize for safe-keeping.) Maybe I’ll do a post on this; feel free to follow-up there. Thanks for writing.

Hello, I need your advice. I have a son who was evicted from his father’s apt. for rude conduct and over two week visting time. His brother brought him to my home. He has relasped since June without his Resperdone. He has lost 40 lbs. and keeps telling us he is fasting to cleanse his body. He is very frail. He appears malnutrition. I told him he could not stay with me until he went back on his medications. He refuses and states he does not need meds. ONly better nutrition. I insisted him to go to ER to check his medical condition of mal nutrition. He went along, then at the hospital ER I mentioned to the nurse that he was wanting to go homeless and wanted no money for food and live like a homeless man, because he did not want to take the meds. The ER doctor saw his weakness and agreed with me that he was hurting himself by starving himself. From the ER after 24 hour hold. He was transferred to a physiciatric hospital where they declared him a 5250. He has had his resie hearing so that he could understand that he needed to be treaed with medication. First two days were ok. The third day he is very angry and wants out ASAP. He wants to come to my house to sort out his life. We have been through this before and he does not comply. He said he was only going to take his medication while he is in the hospital and will not continue when he comes out. How can I inform the doctors if he could be on a medication compliance while he come out. I hate to see him in that mentally ill psych ward. He is very intelligiant. Please help with advice.

Hi Dr. Reidbord,
I work in a psychiatric crisis unit (free standing and without even the option of a 23 hour bed hold) in California. My question has to do with 5150 holds. Because we do not have medical personnel on staff we see many people at our local ER. Recently the ER called us wanting us to evaluate a client with a BAC of 367. This person was a long standing alcoholic and had broken up with a significant other. This person was suicidal. We do not evaluate anyone for a 5150 with a BAC that is over the legal limit, and our reiciving hospitals do not accept anyone who is not at or below the legal limit. The ER doc reported that this person was walking and talking, and therefore fit for evaluation. He also stated that if the person got down to legal limit they would probably go into DT’s. Is there a law about when someone can be evaluated for a 5150 when they are under the influence? Specifically with alcohol, do you know of any guidelines?
Thank you

Hi Anthan,
I’m not aware of any legal prohibition about applying a 5150 to an intoxicated person. I’ve certainly done so in the past, when on-call in a psychiatric emergency service. Remember, though, that the dangerousness justifying a 5150 needs to be due to “a mental disorder.” Simple intoxication is listed in DSM-IV, so I suppose it’s officially a mental disorder, but by the same token so are caffeine intoxication and nicotine withdrawal. To my mind, these stretch the boundaries of what common sense says is a mental disorder. As correctly pointed out by Joe P. above, there is another law, the 5170, that applies in parallel fashion to dangerousness specifically due to acute alcohol intoxication. However, I’ve never seen or heard of it applied.

I was sent to the hospital because my husband stated I awoke incoherent. He said I was stumbling into the kitchen to get some water for my morning medicines. When he asked me what was wrong, was I o.k, he said I said I took 4 sleeping pills I just wanted to sleep. After arriving to the hospital blood tests were taken and all toxins, alcohol levels came back negative. When he arrived shortly after there was a guard at my bedside. He didn’t understand at the time what was going on. After a couple of hours I awoke to a guard, and confused and still a little disoriented ask how and where was I. The guard said I was brought in by ambulance. Talking to my husband he said, I said I took four sleeping pills. Being upset with the situation and scared not knowing what happened. Suddenly a Behavoral Specialist walks to my bedside and introduced herself. She asked my husband to leave against my wishes. I refused to speak to her, she stormed out of the room passing up my husband in the hallway. Then I do not know how long after returns with a piece of paper and tells me she is putting me in a 5150 hold ,That I was suicidal and a harm to myself, handed it to me and left. Being upset and scared I tore it up. I asked the nurse for my pt. right? I have none, No AMA rights nothing.I insisted they check my records as I was recently 5 months prior brought into the hospital with the same symptoms and diagnosed with having a new onset of seizures placed on seizure medicine and have been under the care of a neuralagist since that time. I asked to be checked for another seizure and they refused. I truthfully believe I had another seizure. My husband contacted my primary Dr. I explained to her what was happening and she called the ER dept. to request a EEG. They refused so I was sent to a Behavoral Hospital restrained in the ambulance, frightened and humiliated. Kept Under lock and key. The next day released.

Your comment is off-topic — my post was about people being forced to have medical (not psychiatric) treatment by having a psychiatric hold applied. In your situation, that would have occurred if, for example, doctors applied a 5150 in order to test you for seizures against your will. But I published your comment anyway, as it raises several important points. The first is that assessment of suicide risk is very subjective. In my experience, anyone evaluated in an ER after taking four sleeping pills, even as a self-declared “suicide attempt,” would be released after a few hours, not admitted to inpatient psychiatry. Minor, non-life threatening overdoses are usually considered suicide gestures or parasuicide, not true attempts to die. However, there is nothing in the law that specifies this. Clinical assessment of risk can range from extremely conservative to extremely lackadaisical. In another post I argue that suicide holds are too often applied in knee-jerk fashion

Second, your comment illustrates how medical decision-making can be neglected once a patient is labeled “psychiatric.” Your possible seizure disorder wasn’t taken seriously, even though this could have explained what happened. This is very unfortunate. I believe it stems from discomfort among health care professionals, i.e., those not trained in mental health, to deal with emotional problems. Patients are passed along to “psych” and forgotten by medical teams who feel they have nothing to offer. This can be a big mistake when the apparent psychiatric disorder is really medical. I’ll always remember the severely disturbed patient on the locked psych ward at San Francisco General who was finally given a brain scan that revealed a tumor.

Third, being put on a legal hold, especially the first time, can be very upsetting and frightening. Although it’s true that the patient cannot leave AMA (against medical advice) while the hold is in place, every effort should be made to explain the situation calmly to the patient. Many patients will not like it no matter how it is presented, but health care workers should do the best we can to reduce emotional trauma stemming from the hold itself. Thanks for writing.

I’m an LCSW and work on a PET team in Los Angeles and see patients in the ER. We ran across an interesting issue recently. A Medi-Cal patient was evaluated by one of my colleagues and placed on a 5150. The discharge planner worked diligently to find a bed for this patient but was ultimately unable to do so. So, 72 hours later, we were being asked to re-evaluate the patient. There have been times when we have re-evaluated patients who are no longer psychotic or suicidal and we have “lifted” the hold prior to the completion of the 72 hours, but in this case, the 72 hours had elapsed. The patient remained gravely disabled and discharging him would have been doing him a disservice, but I wasn’t sure if a person could have a second 72 hour hold placed on them.

(I know this is not actually your original issue, but since others have strayed from the topic, I thought I could do so as well. Thank you)

No, you can’t apply another 72 hour hold (5150) in California. Your options are to release him, or to apply a 14-day hold (5250) for grave disability, which then guarantees the patient a hearing, within a few days, before an administrative law judge. The LPS commitment laws were set up this way to assure a judicial review whenever a patient is held against his will longer than the 72 hour evaluation period.

Thanks Dr. Reidbord – I don’t believe that a patient can be placed on a 14 day hold if they’re not in an LPS designated facility. The ER(s) in question are not a part of an LPS Designated facility, so I don’t know that this is an option. Also, my designation given by LA-DMH is only for the 5150. Would the only answer be to d/c this patient from the ED and then immediately re-admit them for another psych eval?

BTW – while googling to try to find the answer, it seems like the issue of holds expiring while awaiting a bed is not uncommon in LA County anymore. And unfortunately, it will likely get worse.

Thanks for your very quick response to my question and I look forward to your response to my second one.

I’m at the limit of my knowledge of such things; I’ve only worked at medical centers where 5250s can be applied. I’ve heard tales of facilities discharging patients when holds expire and then immediately readmitting under another 72 hour hold. This obviously violates the spirit, if not the letter of the law. Patient-rights advocates could validly protest that this potentially endless cycle dodges the legal checks and balances built into the system. I’ve never witnessed it myself.

The problem of holds expiring while awaiting a bed reflects larger dysfunction in our health care system. Patients suffer because short-term, shortsighted economics oppose long-term wellbeing. The money spent holding someone in an ER for three days (because no facility will take a Medi-Cal patient) could pay for a lot of mental health care in other settings. Unfortunately, there’s little an individual practitioner can do about this, other than work for change in American health care generally. Speaking for myself, it would offend my ethics to “solve” this systemic problem by sidestepping the rights of patients. At the same time, it would offend the ethics of many colleagues, myself included, to release such a patient to fend for himself in the street. Bad policy makes for no-win choices. Thanks again for writing.

Thank you Dr. Reidbord. Guess sometimes we can’t find answers because none exist! The “system” seems to be conspiring against being able to do the right thing on behalf or our patients while remaining within the law. Letting a patient go only to turn around and place another hold on them vs. letting a patient go who truly requires hospitalization.

Dr. Reidbord,
Thought you might find this interesting. LA DMH is now considering the start of a 5150 hold to begin when the person enters the locked LPS Designated facility. So even though I may write a hold in the ED on a Friday night, if there is no bed available until 73 hours later, they are saying the hold is still valid and the 72 hours had not even started until the patient arrived at the LPS facility.

Our daughter had been on med-leave from a stress related work situation. She was under the care of her medical dr. and a counselor. Treatment was for anxiety. On the day that her med-leave was to end, she took some pills (she thought maybe 6 at the time), so we took her to the hospital. We gave the pill bottle to the staff. They didn’t count the pills. We later discovered that she had take 3 stomach pills. The nurses and dr. on duty repeatedly asked her if she was trying to hurt herself, and she said no. They wanted to do blood work, but she refused, because she has a major phobia against needles. Before we know it, a social worker is saying she is placing her under the 5150, and that she just needs to convince the dr. to agree. During 3 separate conversations, the social worker compares our daughter to her husband that has avoidance disorder and complains about how difficult it is to live with. Never does she say she is placing her under 5150 because she is suicidal. The social worker also states that in her 8 years of practice she has only had 3 patients that were this obstinate (my daughter being one of them), that she transferred to a psychiatric hospital. As far as we know, a Patient Rights Representative never came to see our daughter. The psychiatric hospital seemed perplexed that she had been placed under the 5150. Since this occurred, I have been researching 5150, and from my understanding and the advise of the Mental Health Advocacy Services, it blatantly was misused and abused. What is our recourse and next step?

You may wish to consult with an attorney. I’m not one, and can’t give legal advice. I can offer my own experience and understanding though. The standard of evidence for applying a 5150 is “probable cause.” Dangerousness doesn’t have to be proven beyond a doubt, but to justify a 5150 there should be a reasonable argument that dangerousness to self or others is substantially likely (“probable”). The person does not have to admit to being suicidal or homicidal. For example, an intentional overdose, if substantial — and this is a judgment call — may be sufficient in itself. “Circumstantial evidence,” reports from third parties, and other kinds of indications can also count. In my experience, patient rights representatives do not routinely meet with patients on 5150s, and some settings do not have such representatives. The patient is afforded legal counsel (a public defender) for 5250 probable cause hearings, but not before.

Obviously there is a lot of subjectivity in applying civil commitment holds, especially for the initial 72 hours (the 5150 in California). It’s an imperfect system that relies on human judgment, and reasonable people can disagree about a given case. As I understand it, and again I’m not a lawyer, if you feel the 5150 was blatantly misused and abused, you can bring a civil or criminal case against the person(s) who applied it, and also perhaps the institution within which this misuse took place. You can also complain to the professional licensing bodies of the professionals in question.

I was placed on a 5150 hold at my local ER. They ended up restraining my feet and hands. They forced a catheter in me against my will. I felt like I was raped. Is it ethical what happened to me? Even if I am placed on a 5150, it is still my body and they don’t have the right to touch my body against my will but they did anyways. They were trying to rush me to a psychiatric facility, and also since the cops were involved the cops may have pressured them to do it. Since I didn’t need to pee they dehydrated me and assaulted me to find out if I was on drugs or not instead of just asking me. I had to beg for water by the security sitter after they forced dehydrated me. I was really just severely sleep deprived to the point of temporary insanity, but now I am suffering from post traumatic stress disorder from this incident because I felt like my rights were violated.

It’s sad and unfortunate this happened, and you may wish to talk to a counselor or therapist to work through the emotional aftermath.

It’s impossible for anyone who wasn’t there to say whether you were treated ethically. It is ethical to restrain someone in an ER who is actively harming himself or others. For example, someone slamming his head into the wall to commit suicide or in response to hallucinated voices would be restrained. So would an enraged or highly agitated person throwing ER equipment at others. If you feel your behavior didn’t justify being restrained you could consult an attorney. The key would be WHY you were restrained, not simply that you were.

The situation with the catheter gets back to my original post and the idea that medical procedures are neither permitted nor forbidden by being on a psychiatric hold. Leaving psychiatry and 5150s aside, any patient brought to the ER with “altered mental status” — delirium, confusion, agitation, bizarre behavior, or similar states — needs an immediate medical diagnosis and treatment. Severe sleep deprivation is one possible contributor, but so are a long list of other possibilities: recreational drugs, medication overdose, seizures, brain trauma, etc etc. Such conditions are usually considered life-threatening emergencies, where ER personnel are ethically expected to do whatever they believe is in the best interest of the patient, including tests the patient may not want at the time. As with the restraints, you may wish to consult an attorney if you feel this treatment was unjustified, but the simple fact that it happened doesn’t make the case one way or the other.

Again, regardless of the ethical or legal status of what happened, you’ve suffered emotional trauma from the experience. Getting help for your feelings is a separate matter than making the case that you were assaulted or your rights were violated. Take care.

I was restrained for streaking outside of the ER. I lost my patience and became irrational because I hadn’t slept in days so I told my mom to take me to a different doctor since the doctors were ignoring me for several hours in the ER. I yelled at her, “if you love me than why are you trying to kill me” because I felt that I was dying from not sleeping for so long. I ran out of the hospital and my mom chased me. To get her and the hospital away from me I took off my shirt and ran down the street. A cop car followed me and asked me if I needed a ride. I told him to take me home, and instead he drove me back to the ER. I grew more upset that the officer lied to me and brought me back to a hospital where they were ignoring me so I took all my clothes off in the cop car because I figured the doctors couldn’t ignore anatomy since they were ignoring my mental condition. I blacked out likely from sleep deprivation,trauma, or possibly because of a taser. The next thing I realize I’m in an ER room restrained and naked with a blanket covering me. Three nurses came in the room and unethically did not tell me their names or what they were going to do to me. Because I had been deprived of sleep for so long the only thing I could tell them was that they were molesters because they were touching me against my will. They walked out and brought in a security guard and proceeded to catheterize me even though I was still calling them molesters. I couldn’t do anything to keep them away from my body because I was restrained therefore the restraints made it feel more like a medical rape. Just because I had gotten naked in a cop car did not mean that I wanted anyone to actually see me full on naked but the nurses disregarded my bodily privacy during the entire procedure. After they left the room, I told them they were inhuman and the security guard at my door made a gesture with his hand for me to be quiet. They also dehydrated me so I had to beg the security guard for water. That’s when my senses came back to me because I was so upset over the forced medical procedure. I told the security guard I had been trying to take melatonin but couldn’t sleep and that I was not on drugs. The nurse then walked in and gave me medicine so that I could sleep. I feel that the way the situation was handled was not ethical and I would have rather been charged with public nudity and taken home than treated at that hospital. At least than I could fight the charge of nudity due to temporary insanity and my body wouldn’t have been touched against my will.

Perhaps this is outside of the scope of this discussion, but what about the person who cannot afford medical treatment and cogently refuses such treatment. For argument sake, just assume that government financial assistance is either unavailable bureaucratically untenable. Can a person in CA be treated as a 5150 in order to force them to have medical treatment, then upon release in 72 hours, be forced to pay for the forced medical treatment? See where I am going here? Even with the Affordable Care Act, there are situations where a person may choose not to opt for medical treatment (e.g., costly surgery, expensive prescriptions, etc.) where they choose not to be indebted for years to come. Perhaps a person would prefer the dignity of a shorter life under moderate conditions than a longer life under impoverished conditions. Can someone be put into a 5150 scenario to be forced into treatment, then be forced to pay for said involuntary treatment?

A person in California can’t be treated as a 5150 in order to force them to have medical treatment, for the reasons described in the post. Cogent refusals of treatment can be for any reason, including financial. However, a Californian can be hospitalized on a 5150 for psychiatric reasons, and then receive a bill for this treatment later.

My roommate, after having had a very difficult afternoon dealing with an ex-spouse who was not paying any child support (despite his ability to do so- he quit a lucrative job in order to not pay); and, her struggles to make ends meet while working full time with three children, took 10 benadryl tablets in a cry for help. I am certain she was not trying to kill herself. She said as much at the time. Also, she has never displayed any suicidal symptoms or expressed any such thoughts to me or anyone. I think she just had a disconnect between the act and the potential consequences of the act. That being said, I found her crying and after she told me what had happened, I took her to the Emergency Room not knowing whether she could die from the 500 mg benadryl dose. After an assessment by a social worker and M.D. (not a psychiatrist) she was placed on a 5150. We had no idea this would turn into a nightmare involuntary detention. She was just told you’re going to a psyche facility, which could last for up to 72 hours, but that she could be released earlier. My research shows that if someone is not a harm to herself, others, or gravely ill, they can be released. She spent the night at the facility to which she was transferred, was cooperative, lucid, made clear she was not intent on hurting herself or others, and is good health. She waited all day for the psychiatrist assigned to her to do an assessment. We were hoping he would see what the staff and everyone else saw during the day– that she realized she’d made a mistake, but had no intent to hurt herself or others. And that she was eager to get home to family and friends who were waiting to give her support. We had told the staff earlier that family members were waiting for her to come home that night. The facility is scary, the 5150 ward has persons with severe mental disorders freely roaming the halls, screams during the night, etc. My roommate was traumatized by that environment. When the psyche M.D. arrived at 9:30 p.m., the first words out of his mouth were: “I know you want to go home, but you will have to stay for 72 hours because that is what the “hold” requires.” This was before he even spoke with her regarding her condition. He was arrogant and spent all of three minutes with my roommate. After, I called the facility to inquire whether there was an appeals process where we could get a second opinion. I also expressed my dismay in the random, arbitrary and the non-due process way in which he summarily decided she would have to stay at the facility (she has no health insurance and does not qualify for Medical– I read the prior post on this). It seems so unjust and will result in a huge payable that will dog her for years. Is there any recourse against the facility or doctor? Is it just his “word” and that’s it?? When he found out that I had inquired about an appeal or challenge to his decision, he implied in a veiled comment to her that my involvement could lead to her having to stay longer. I am listed as her next of kin on the admit forms. His veiled threat seems unethical. Moreover, requiring her to stay at the facility which is not providing any meaningful counseling is having the opposite effect.

Our 44 yr old son was taken from a hotel room to a hospital in Pleasanton on a 5150. He had left a sober house and was drunk and overdosing. He suffers fro CTE football concussions. He is incapable of taking care of himself. We tried caring for him in our home but he finally got physically abusive of us. We had to have him incarcerated. He left Texas and ran to CA. He is to be released in 72 hours. He needs to be in a mental hospital. We are helpless and so is he.

In the county where I live a “new” guideline has been presented by the county that says that when a mentally ill patient meets criteria for 5150, seen in a medical center ED, and is put on a hold by a designated person that as soon as the designated person leaves the hospital premises, the hold is void and even if the patient came in after a serious suicide attempt, the patient can leave ama. is this a new ca law? what if the patient kills him/herself? who is responsible?

I haven’t heard of this before, and it’s not immediately clear how this works. Maybe the county guideline is that a 5150 placed in the ED must lead to hospitalization somewhere, before the person placing it can leave the premises? That’s the only way I can make sense of it: ED’s (and county governments) are motivated to move such patients to a secure inpatient unit ASAP, and they don’t want to re-evaluate the legal hold in the meantime. If I’m right to understand it this way, the guideline isn’t an invitation to release dangerous people. It’s pressure to get such patients hospitalized and out of the ED. The medical center (and/or the designated person, if it were his or her decision) would be responsible if a dangerous person were released.

Hello Doctor,
I live in the Pasadena area and found your blog to be very helpful but I have a question.

What would you recommend doing in my situation?

At the end of last August I had a three day migraine which is not frequent but not uncommon for me. I had run out of my medication for it and didn’t have the budget for a refill.

As I’m sure you know about all one can do is lie in bed and try not to feel miserable. You often drift asleep which always causes a sleep schedule drift. I’ve always been able to shift back after some work, but I had probably more than the usual stress because my brother had been coming to criticize me more than usual (another story).

I found that I simply could not sleep for three days. I was not at all depressed and have never been anything but a sociable and naturally optimistic person i.e. I’m the antithesis of danger to anyone.

By the third day, I was exhausted which frightened me so after recommendations to go to the local ER, I called a friend for a ride and to watch my dog for what I thought would be some hours of waiting then an examination and prescription.

I was always aware of being careful not to ever say anything which might cause a clinician to feel that I might either be a danger to myself or others and truly was not.

At the most, I expected an overnight examination. I found myself on a gurney in the brightly lit hall in front of the Psychiatric admission desk and was left there for at least one or two more days.

The next thing I knew was that I was to be transported to another hospital.

An RN from the other hospital came to interview me and asked how I felt. I told her that at that point after nearly a week of no sleep that I was exhausted and if I had to go shopping that I was frightened of driving in less than a fully awake state. (I found later that she had written that I said “I was frightened of what I might do.” Clearly wrong and possibly deliberate.

I had no idea and no one told me that I had been defined as a 5150 and being sent for a 72 hour hold.

I have regular meds for chronic insomnia which made things worse. Because it was on a Saturday after midnight when I arrived it would be until either Monday or Tuesday that I could see my assigned psychiatrist.

I can say with pride that I had no auditory nor visual hallucinations simply due to sleep deprivation which btw seems like a very bad time to interview a patient who was offered no prescription which I ordinarily take.

I decided that unlike most of the patients there who where all levels of functionality and criminals that I would just be me. The rest would naturally put a facade on as soon as they entered their assigned doctor’s office. I behaved rationally, with grace and kindness.

The determination has closed many doors for me and was absolutely unjust.

I would like to get both my rights back as well as have such an absurd history erased.

Is this possible? I am confident that if I talked at length to any experienced specialist of either violence risk factors or self-destructive tendencies, there would be no problems and I’d take any test including that long boring MMPI and there would be no problems.

I really would like to email you if possible because there are some relevant factors going on. My brother is a Cardiologist with patients at that hospital and he had let slip that he and his wife wanted to sell my family’s house and were trying to come up with a way to do it.

I know speaking to an attorney would be the most logical answer but wondered what you thought of my situation after hearing about the other pieces of the story I haven’t mentioned here – otherwise it would be like a Tolstoy novel.

My only recommendation is to speak with an attorney if you feel your rights were violated. Please do not send me “other pieces of the story” or additional information. I write and manage this blog on my own time, and do not have the time or interest to analyze complex personal situations. My apologies, and best wishes.

Say a person has a history of suicidal tendencies. The patient was released from a psychiatric hospital 6 months prior to an incident. The patient is intoxicated and is bleeding profusely. The patient gets out of the bed and leaves the hospital. Say the patient returned and accepted medical assistance. The cut on the patients arm was potentially life threatening. Then the patient was released with no psychiatric consult nor suggestion of a psychiatric consult after the incident. If the patient claims they do not remember how the wound happened is it legal for the hospital to allow the patient to leave?

It’s a judgment call. If the cut on the arm looked like a suicide attempt, then a psychiatric hold would usually be applied. Since it’s a clinical judgment whether a patient is a suicide risk, “legality” isn’t the issue. Of course, doctors and hospitals can be sued (i.e., civil not criminal liability) either way: applying a hold when it isn’t justified, or failing to apply one when it is. If the cut was really life-threatening, it should have been repaired regardless, at least to the point of it not being life-threatening anymore.

Intoxicated patients may truly not remember what happened and still be dangerous to themselves or others. This is usually handled as with other cases of delirium, that is, with implied consent but without psychiatric involvement. However, patients with a “psych history” (past hospitalization, documented severe psych diagnosis, “suicidal tendencies”) tend to bias medical personnel toward treating subsequent self-harmful behavior as psychiatric, even though such patients can get drunk, etc, like anyone else. In a larger sense, this illustrates the often fuzzy boundary between psychiatric and medical disability. Thanks for writing.

Is a refusal by the psychiatric evaluating facility to examine underlying medically and mentally disabling conditions such as ongoing Advanced Liver Disease with ascites cause for nullifying/reversing a 5150/5250 hold? The patient refused medications that were contraindicated for hepatic failure and this led to multiple transfers between facilities. What would the best course of action for the patient to take if they wanted to pursue removal of these holds from their records? Is this just an administrative matter?

I don’t know in this case. Usually if it’s a simple error of medical data, the original doctor or other provider writes an addendum to the medical record noting the correction. (In general, nothing is ever “removed” from a medical record, even if it’s clearly an error. Instead, a correction is added.) A case like this sounds more complicated, i.e., a matter of judgment and an implied allegation of neglect, i.e., failure to examine underlying medical conditions. Consulting with an attorney may be helpful.

Hello, I have a question. One of my friends was placed on a 5150 hold at a 24 hour crisis unit and they said that he is supposed to be sent to as psychiatric hospital to be evaluated. But if he hasnt been evaluated or sent to the hospital after 72 hours, by law do they have to release him. Honestly he is not a harm to himself.

Thank you for addressing, this very important issue,
it is long over due. If we are honest most of us that are from the medical community have at one time or another seen this happen.

The issue is when the patient reports, to the licensing agencies, advocates, Lawyers, media,
or law Enforcement, that a crime has been committed.
there is disbelief.
For some reason, the Idea that a Doctor, could do such a thing, is not acceptable.

I have a complete case, documented evidence, medical records, a copy of a false and illegal 72 hour hold.

So far no one will even investigate my claim, I have taken to all the proper boards and reporting agencies,
none have even contacted me for the evidence I have.

I’m afraid I don’t have much else to suggest. An attorney would be in the best position to say whether there is a case to pursue. Note that a “crime” is not required for there to be a valid legal case, i.e., a medical malpractice lawsuit. However, it is not considered malpractice to make an honest mistake that colleagues in a similar situation would also likely have made. Doctors and other professionals are held to the standards of our profession, not to a standard of perfection.

If you already tried all these avenues and no one wants to pursue it, your claim may not be as strong as you believe. For what it’s worth, I think there is enough skepticism about doctors these days that we are not “given a pass” when there is provable negligence or malpractice. Thanks for writing.

I’m not a lawyer, but my understanding is that it depends on what “reasonable” or “community standard” ED personnel would do under similar circumstances. In other words, if the patient was so “altered” that reasonable health care professionals would not release him, then the professionals in your example could be found liable. Exactly who would be at fault (doctor, primary nurse, hospital, etc), I cannot say. Of course, if the patient snuck out or “escaped” when known to be dangerous, this would be a different kind of liability.

A couple of quick questions:
Would it be possible for you to suggest or recommend a Lawyer or type of Lawyer that deals with these issues in CA?
Do you review medical records and consult as part of your practice —meaning would you look at the patients medical/psychiatric records and consult with the current Psychiatrist that is dealing with this issue?

1. I have no individuals to recommend. Your earlier comment alleged medical malpractice. Many lawyers specialize in “med mal” cases and represent plaintiffs. Such an attorney would review the facts with you, and decide whether you have a legal case worth pursuing.

2. This isn’t currently part of my practice, but I wouldn’t rule it out as a possibility. If you are considering legal action, the attorney you hire may, in turn, hire an expert witness (i.e., a psychiatrist) on your behalf to review records and offer a written opinion that can be used in court.